Provider Demographics
NPI:1801920467
Name:WEATHERSPOON, BRYAN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:CHARLES
Last Name:WEATHERSPOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6836
Mailing Address - Country:US
Mailing Address - Phone:912-673-9355
Mailing Address - Fax:912-673-6532
Practice Address - Street 1:51 LINDSEY LN
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6836
Practice Address - Country:US
Practice Address - Phone:912-673-9355
Practice Address - Fax:912-673-6532
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033482208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE49426Medicare UPIN